Saturday, November 11, 2006

The Meaning of a Medical Visit

I think we're taught wrong in medical school. Or perhaps I just learned it wrong.

I used to think that being a physician was about treating patients' diseases. If Mr. X has hypertension, the treatment is antihypertensive medications. If Mr. Y has diabetes, we need to get control of his blood sugar. If Mr. Z comes in with a spot that looks like skin cancer, it needs to be biopsied. If it's skin cancer, we need to cut it out.

All this is still true. But not the whole truth.

These are all knee-jerk responses to different diseases that we see in patients. We're taught to hone our skills continuously so that we can best detect and treat disease. We're taught and tested and mentored so that our physical exam is done well. There are classes that teach you how to ask your questions so that you get the answers you need to make a diagnosis. There are classes (can you imagine!) that teach the budding medical student that there are two agendas during each patient encounter. The first is the agenda that the patient has - why they are here. The second, most importantly, is the physician's agenda - to treat the high cholesterol, to talk about weight loss, to freeze a precancerous skin lesion. You do this because there may be medical issues that do not bother the patient, but treating these today may prevent health problems in the future.

You feel good if you're able to take care of issues on your agenda. After all, if you cut out a skin cancer, you did good, right? If you push down the blood pressure, you're decreasing the long-term strain on the heart, right? Perhaps.

But in truth, what you did during that visit is no more than what you did during that visit. Increasing a patient's Metformin dose is nothing more than just that. If she does not watch her diet, the medication change may not have any effect on blood sugar control. Which means that she's still at the same risk for long-term complications. Cutting out a skin cancer is nothing more than the physical act of removing a skin cancer. It does not mean that the cancer will not recur. Or, in the case of more serious skin cancers, that the patient will not die from the disease.

All medical decisions are based on the presumed benefits and risks of treatment. If the benefits greatly outweigh the risks, it makes sense to proceed.

There are certain situations where it is easier to guestimate these things. If it's a young person with a precancerous lesion, the temporary discomfort from liquid nitrogen is worth the possible prevention of a future skin cancer. In a patient with advanced dementia, who cannot understand who you are and what you're doing to them, who has a short expected life span, it may be more humane to leave them be and not inflict pain for long-term benefits.

But weighing risks and benefits presupposes that we can predict the future. It assumes that a 25 year old man will outlive a 73 year old woman. It assumes that a healthy 80 year old man may tolerate general anesthesia better than a 70 year old with multiple medical problems. All good assumptions, but really nothing more than educated guesses based on prior experience. Which are not always correct.

We tend to forget that we're all "terminal" patients with a common fate. Who knows what our "prognosis" is? Can I say that I will be here next year? No. Can I say that Mrs. Y will make it through the month? We can only say that it is likely but never for sure. If I send an apparently healthy 85 year old patient to the OR for a melanoma excision, am I doing good by the patient? Perhaps if he makes it out alive and well. And if he lives to 95 or 100 without a recurrence of melanoma. What if he dies on the table because the cardiopulmonary stress test of the situation unmasked latent disease? Did I still do good??

I don't know what the answers are. The only conclusion may be that we are responsible for the intent behind the decision. That we should carefully weigh important factors, provide a medical recommendation, and discuss the risks and benefits with the patient. That what happens after that is a complex interplay between life and fate far beyond our control.

But perhaps what's important is not your agenda or my agenda. Perhaps it's the recognition of the weaving strands of life that bring together the lives of two people for a special occasion. And perhaps the truth is that the most sacred part of medicine is to see this, and know that it is not what we do that matters, but how we do what we do.

photo credit


Anonymous Happy-heart-patient said...

Your writing is very insightful, including your previous "....Roses". You seem to get it, and sound like you are becoming a wonderful doctor who will spend those extra moments with their patients to build a relationship with them. Beleive me, they do appreciate it, and that relationship can make a difference in their lives. I look forward to reading your future posts.

5:30 AM  
Blogger always learning said...

Welcome Happy-heart-patient!

Thanks for your comment. I went into medicine to take care of people. Training can one lose sight of that, but thankfully, it's coming back :)

Happy Thanksgiving to you and your loved ones :)

11:02 AM  
Anonymous Kim said...


Just dang!

Great post.

5:30 PM  
Blogger always learning said...

Hi Kim!

Thanks for reading :)

12:13 PM  

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